For discussion and debate about the ethics of health care organizations and the wider health system.

Saturday, February 13, 2010

Murder conviction and Malpractice Accusation in Massachusetts

This week a Massachusetts jury found Carolyn Riley guilty of second degree murder for causing the death of her four year old daughter Rebecca by giving her an excessive dose of psychotropic medication.

But when jurors were interviewed after the trial they also expressed outrage at Dr. Kayoko Kifuji, the psychiatrist who prescribed the medication. One juror said Dr. Kifuji "should be sitting in the defendant's chair, too!" And she will in a year or so when the malpractice case brought against her by Rebecca's estate comes to trial.

Rebecca's death reflects two psychiatric tragedies.

First, Dr. Kifuji relied on "data" presented by Rebecca's mother in making her assessment. This is intrinsic to psychiatry. We don't have tests that demonstrate the presence or absence of a condition. We have to rely in significant part on what people tell us. The prosecutors alleged that Carolyn Riley and her husband Michael (who goes on trial next month) deliberately lied to Dr. Kifuji and others to elicit a psychiatric diagnosis that would allow them to collect disability benefits for their children.

We physicians cause harm when we're too skeptical, as when we misdiagnose the pain of a sickle cell crisis as duplicitous opiate-seeking, and when we're too trusting, as the prosecutors allege happened in dealing with the Rileys. Ideally we'd get the balance of trust and skepticism exactly right every time. But that's not possible.

In practice (and in life) I asked myself which mistake I'd rather make, and whenever possible explained my reasoning to the patient. Making a mistake isn't malpractice. Juries, and patients, will forgive an "honest mistake" if we've thought through a situation carefully, have been forthcoming about the rationale for what we're recommending, and treated the patient with respect and compassion.

The question at Dr. Kifuji's malpractice trial shouldn't be whether she made a mistake, but whether she acted with prudence and skill.

The second psychiatric tragedy is intrinsic to the field itself. It's hard for the field, and for individuals, to integrate the biological, psychological, and social components of what we are. We prefer simple explanations to acknowledging complexity and ambiguity.

When I did my training, the pendulum had swung way too far in the psychological direction, and I saw mothers being accused of causing schizophrenia and autism by being cold and rejecting. (I'm happy to be able to say that I never joined that bandwagon.) Now the pendulum is way too biological and we "accuse" children of being biologically off and needing medication when they're restless and bored in school or unhappy at home.

What's happening in psychiatry is a milder version of the polarization we're seeing in our political process. Conservatives blame feckless individuals for their problems. Liberals put the blame on uncaring society. For most issues, both are partly right, partly wrong. But threading our way towards an integrated perspective on complexity seems beyond our national capacity at present.

I'm sorry for whatever the experiences are behind your view of health care and ethics as "widely different categories." I'm guessing that what you mean is that you don't see your views of what constitutes the right kind of health care embodied in the system you are part of. If your view is that the "system" we have is too procedure oriented, too focused on technologies and too little on what we can do to advance our own well-being through the way we lead our lives, I agree with you.

About Me

I've been in health care for almost 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about. I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings.